PNHP

The best health care solution? Medicare for all.

The best health care solution? Medicare for all.

By John H. Clark
The Charlotte Observer, August 1, 2017

The 52nd anniversary of Medicare was Sunday and the program is more relevant than ever no matter your age.

If you’re younger than 50 or even 40, you may benefit from a brief description of Medicare. “Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease” (Medicare website). Congress created it in 1965 to aid older citizens who had no insurance coverage following retirement.

The health care issue is raging in the headlines and if you’re following the roller-coaster ride in Congress, regardless of party affiliation, you have to be shaking your head. There is a much better approach to all of this, and the Medicare model is a sensible place to begin.

Medicare has been a godsend to older citizens who either did not have continued coverage from their employer plans or had only minimal individual coverage before the age of 65. The cost of running the Medicare system has been very efficient, easily outpacing the private insurance market in controlling costs.

A “Medicare for All” or “Single Payer” program makes the most sense and is possible if people demand it. What would such a program look like? How would it be different from the 52-year-old Medicare program?

First of all, a single-payer program would cover everyone through a non-profit public entity. The couple in their late 20s who are awed witnessing the birth of their daughter will know she is covered immediately. The 54-year-old man who loses his job will be consoled by knowing his ability to pay for his medical care or that of his children will not disappear as it does today.

Secondly, each individual or family will have no co-pays or deductibles. They will enjoy universal choice of their physicians, clinics and hospitals. There will be no lifetime caps on expenses.

Too good to be true? Not at all.

Who will pay? Eliminating the for-profit private insurance system will save at least $600.8 billion per year in administrative costs plus outpatient prescription drug costs, according to Annals of Internal Medicine. Doctor and hospital staff negotiating with health insurance company staffs over charges, tests, etc.? Gone. With no premiums there would be new, modest taxes based on one’s ability to pay. And 95 percent of families would save money compared with the current system.

The Commonwealth Fund’s 2014 report on international health system efficiency ranks the United States last of 11 developed nations on measures such as quality of care, access to care, efficiency of care and equity of care.

OK, those who are 50 or younger, are you interested? One other matter – a single-payer program is not socialism. Doctors, clinics and hospitals are free to practice medicine as they know best. A single-payer approach is simply a better financial way to fund health care in this country.

What next? Call your U.S. senator and U.S. representative and tell them what you think. The most recent action in the Congress is rather frightening given the facts.

And facts matter.

John H. Clark is a member of the Charlotte-based Health Care Justice North Carolina.

http://www.charlotteobserver.com…

Single payer vs. universal public coverage through managed competition

Universal Health Coverage? Why?

By Walter McClure, Alain Enthoven, and Tim McDonald
Health Affairs Blog, July 25, 2017

The Congressional health care debate has become a war between two seemingly irreconcilable extremes, coverage versus budget control. Health care is a right, thunders Bernie Sanders (I-VT). There’s no free lunch, roars back Rand Paul (R-KY). We think both sides miss the boat. Forcing health care into this simplistic left-right straitjacket misleads the nation. It is time to recast the issue properly.

Public Investment

Universal health coverage is better viewed as neither owed to us by government nor a govern­ment give-away; both labels misinform. A more insightful analogy is universal public edu­cation. Does government owe people a public education? Is universal public educa­tion a handout to “takers” who ought to go out and buy it on their own?

When universal public education was first proposed, many of the privileged might have said, what do you want to educate “those” people for, you are just throwing away our tax dollars; if people wish education for their children, let them go out and buy it … ignoring that many could not afford it. Fortunately, we did not listen. We wisely invested in public education for all, and the productivity of our workforce boomed.

In the same way, universal health coverage is a wise public investment. Done right, it will return far more to our national prosperity than it costs in tax dollars.

Perverse Incentives

The crucial caveat is “done right.” Neither Medicare, nor Obamacare, nor the unsound private health insurance market have yet done that kind of broad public investment right. All three lack serious incentives on providers to focus on the long-term, reducing cost while raising quality and keeping people healthy; indeed, the incentives are to raise cost no matter the quality. In particular, all three totally lack either means or incentives for patients to iden­tify and choose providers who are better for less over those who are more costly.

The left’s faith in “single-payer” has proven ill-founded; we have had a public single-payer program for 50 years, Medicare, that absolutely controls the over-65 market. Yet despite the best efforts of the agency its costs still balloon out of control. The right’s faith in the private health care and insurance markets has proven equally ill-founded because both are severely unsound and, as Adam Smith taught us, unsound markets do not self-correct. As a consequence, in the same five decades the private market has done no better than Medicare on cost control. Five decades of efforts by both approaches using bureaucratic controls, micro­manage­ment, and token bonuses to make providers efficient have failed to contain run-away cost.

Looking Beyond The Symptoms

If the object is to broaden and improve the productivity of our workforce, then trying to contain cost by butchering eligibility, benefits, or quality of care and coverage is false economy of the worst order.

The correct approach to true cost containment is to drastically improve the quality and productivity of our bloated medical care system.

It’s not that we don’t know how to practice this kind of medicine, ample research studies show we do. It’s that the present system punishes providers with less revenue if they seriously try, and the most efficient are hurt most of all. It rewards those who run up costs regardless of quality. And because most medical care is a judgment call, there is no way that bureau­crats can second-guess doctors into serious cost contain­ment. But, patients, if properly informed and incented and thereby enabled to freely choose providers for value, would hold them to account by their choices far better than any regulators, public or private, ever could.

In other words, the runaway cost and compromised quality of our present health care system are symptoms of a deeper diagnosis: powerful perverse incentives. Policy keeps missing the diagnosis and treating the symptoms

Moving Beyond ‘Single-Payer Versus Private Market’

We need patients choosing among provider groups and delivery systems, not individual services. Patients generally don’t know what services they need, that’s why one goes to medical school; so a market of individual services makes no sense. Choosing a provider group, on the other hand is something we can expect of informed patients. And once provider groups learn that patients are choosing them based on the value they provide, those groups will begin choosing to deliver the services and referrals that get the best results at least cost, and may, desirably, begin to consolidate into more efficient integrated delivery systems. In short, if we turn the present perverse incentives around—by giving patients (1) objective ratings showing which provider groups are better for less, and (2) rewards consumers to choose them over costly providers (both objectives feasible in practice)—we can, slowly but surely, turn our health care system around into the high-quality, efficient system we seek for our children, our workforce, and our elderly.

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Comments:

By Richard N. Gottfried (Chairman of the New York Assembly Committee on Health):
 
Any set of payment methodologies or delivery system reforms can be done in a way that does good or ill. If we have insurance company payers, they will use their power to serve their interests well, not ours. With a public payer, there is a much better chance that the payer will work for change that is in the public interest. And if the wealthy and powerful are in the same boat as the rest of us, they will make sure they’re in a good boat, and the rest of us will benefit. Yes, a universal coverage system should be “done right.” A single-payer system is how we have the best chance at a system that serves the public, not insurance company stockholders. And a single-payer system enables us to remove financial barriers to care and pay for it fairly, based on ability to pay.

By Don McCanne, M.D.

It’s great that the authors remind us about some of the serious policy defects in our health care system, but there are a few issues here that warrant special comment.

Kenneth Arrow told us why markets do not work well in health care. The efforts to provide patient-consumers with price and quality information have not been very effective, whereas inducing price sensitivity through cost sharing, especially large deductibles, provides an example of an approach that the authors warn us against – “trying to contain cost by butchering eligibility, benefits, or quality of care and coverage.” Unleashing health care shoppers is not the path to value.

The authors have long supported competition between truly integrated health care delivery systems – “managed competition.” But assume each system provides comprehensive services. Oversimplifying, yet making a point by using a graphic construct, imagine four competing integrated systems located on four corners of a central intersection in a large city, each with a full complement of services, including specialized services such as cardiac surgery units or neuroscience centers. That duplication of services obviously is wasteful, not to mention that it would still be difficult to shop which integrated system to join for all future care. Since clustering them is not logical, should we spread them out so they serve the four quadrants of the city? Then health care shoppers are more likely to choose based on geographical considerations since bypassing your own center to go to one of the others would impair access because of transportation challenges, not to mention that having coverage under one system would prevent access to noted specialized services in the other centers. And satellite clinics? Do the four systems provide four competing clinics in each suburb or rural community?

It would be far better to have our entire healthcare system integrated. That can best be done though central planning and separate budgeting of capital improvements. That would greatly diminish the waste that we now have because of duplication in competing systems, while ensuring that access to appropriate facilities and services would be more optimal.

In contrasting free market solutions with a publicly financed and administered single payer system, the authors suggest that these are two extremes of political ideology, creating a “simplistic left-right straitjacket.” But when you look at the important issues in health care such as universality, access, affordability, efficiency, equity, and choice of health care providers, it is the public system and not the private market that is designed to ensure that those goals are met. Think of the freedom in the traditional Medicare program and contrast that with the private insurance system (narrow networks, high premiums, high deductibles, instability of coverage, administrative waste, inequity, etc.), and the straitjacket seems to be in the market.

A well designed single payer system – an improved Medicare for all – would provide a framework in which to incentivize quality and value. Integrated systems such as Kaiser Permanente would still provide services within a single payer financing system, but displacing our entire health care delivery system with a cluster of Kaiser Permanente-type entities is not a practical or efficient solution.

(There are also excellent comments by Sarah K. Weinberg and Johnathon Ross available at the link below.)

http://healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The authors support public universal health coverage while rejecting single payer on the left and private insurance markets on the right as “two seemingly irreconcilable extremes, coverage versus budget control,” yet they advocate for competing integrated delivery systems – Alain Enthoven’s dream of “managed competition.”

Dismissing the “simplistic left-right straitjacket” as if it represented two equally ill-advised extremes is in itself a simplistic approach to health policy. The recent Republican effort to get private health insurance right is only the latest example of the deficiency inherent in the fragmented private insurance and public program model of financing health care. We have had over half of a century of experience to prove that it doesn’t work.

In contrast, a well designed single payer model not only resolves most issues with the financing of health care, but it also improves the distribution and efficiency in utilization of resources (see https://www.pnhp.org/nhi).

The authors’ suggestion that the entire health care delivery system be integrated into individual competing delivery systems, like Kaiser Permanente, does not substitute for many of the design features and goals of a single payer system. Plus the concept introduces new logistical challenges such as inefficient duplication of facilities and services, and failure to cover regions that do not support the business plans of the integrated systems.

Patient choice of integrated delivery systems can certainly be included in a single payer system, but such integrated systems alone cannot duplicate all of the important functions of a single payer system that would ensure true universality, access, affordability, efficiency, equity, and choice of health care providers.

Health care professionals and institutions could still compete on perceived quality and service, but we should use central planning to avoid inefficient, wasteful duplication of facilities and services under the theory that we should be promoting price competition in the marketplace. Public administered pricing based on legitimate costs and fair margins is more effective and more efficient.

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After Trumpcare

Republicans wanted to repeal Obamacare and gut Medicaid. Instead they galvanized the push for Medicare for All.

By Adam Gaffney, M.D.
Jacobin, July 30, 2017

The life of Trumpcare was, to repurpose Thomas Hobbes’s words, “nasty, brutish, and short.”

Born in March in the Republican-controlled House, Trumpcare succumbed in the Senate this past week thanks to its fundamentally defective design and pitiable unpopularity, along with the relentless pummeling it received from enraged constituents across the country. After a dramatic vote Thursday night on the final “skinny” version of repeal, it seems safe to say that Trumpcare is now finally where it belongs: six feet under.

The ramifications of this saga will be many and long lasting. One possible effect is a rather paradoxical one: Trumpcare’s architects were intent on undermining the progressive elements of the health care system (for instance, by gradually squeezing Medicaid and degrading protections for the chronically ill), yet they may have wound up bolstering them — most notably, by sparking widespread indignation and resistance.

For though a host of factors helped bring down Trumpcare, we shouldn’t neglect the role of activists — whether it was disability-rights organizations like ADAPT or left groups like Democratic Socialists of America — who never let the bill’s human cost fade from public view.

Vox’s Jeff Stein chronicled many of their actions in recent months: the eighty activists from twenty-one states who were arrested after bursting into the offices of some eighteen Republican lawmakers earlier this month; the disabled Coloradans — several in wheelchairs — who camped out for days in Sen. Cory Gardner’s office in late June; the roughly fifty brave disabled individuals who were hauled away by police for opposing Trumpcare in Sen. Mitch McConnell’s office about a month ago.

The pressure simply did not let up, especially during the final stretch. As Senate Republicans moved into the eleventh hour of their repeal effort this week, protestors hounded them from the chamber’s gallery, chanting: “Don’t kill us, kill the bill!”

Trumpcare ultimately fractured the Right. But it powerfully united grassroots progressives and leftists.

A related factor in Trumpcare’s death was progressives’ swift victory in framing the debate in the moral language of life and death. Scoring from the Congressional Budget Office — which estimated that Trumpcare would leave 20 million more people uninsured — was widely cast as damning, and various observers proceeded to quantify the bloodshed that could be expected to flow from such a reckless withdrawal of health care access.

Republicans couldn’t own any of this. Instead they were forced to respond with a hopelessly ineffective combination of obfuscation and deceit. Earlier this month on Fox, for instance, Secretary of Health and Human Services Tom Price made the comical claim that “we’re going to be able to cover more individuals on this bill than are currently covered.”

Yet Price’s lie can also be seen as almost encouraging: it was essentially a concession that universal coverage should be our common moral ambition.

Similarly, consider the emotional debate over “pre-existing conditions.” The idea that people should be punished for their illnesses received widespread condemnation throughout the Trumpcare debacle (witness Jimmy Kimmel’s viral monologue about his sick newborn son), but for the most part, the House and Senate bills included provisions that would have effectively worsened protections for the sick. Again, Republicans had to respond to criticism with duplicity, as when President Trump tweeted that Republicans would surely be “taking care of pre-existing conditions!”

Even before they lost the repeal battle, in other words, Republicans had already lost the moral war. As a result, the Obamacare repeal effort — or more precisely, the response it provoked — may have inadvertently strengthened the conceptualization of health care as a basic social right.

Conservative commentator Charles Krauthammer conceded as much back in March, noting that Medicare for All could be the next logical demand in the coming years.

After all, the case has now been made that uninsurance is a species of violence. So if it is morally abhorrent to leave nearly 50 million uninsured (as Trumpcare would have done), why is it acceptable to leave 28 million uncovered (as the status quo law will do)?

And if it is beyond the pale to punish people with pre-existing conditions by charging them higher premiums, how is it appropriate to force them to pay handsomely at the point of health care use (through deductibles) simply because they have more medical needs?

It’s worth restating again: there is now a broad consensus that being sick should not mean paying more for health care through premiums. This exact same logic, however, would seem to preclude forcing the sick to pay more for health care through cost sharing. There simply is not much daylight between risk-adjusted premiums and deductibles: both function as types of taxes on the sick.

The activists resisting Trumpcare decried uninsurance and underinsurance as gravely immoral, framing that helped slay the venomous bill. But these ideas — and these passions — will not now suddenly melt away in the summer heat.

Trumpcare’s authors were hoping to deliver the coup de grâce to health care universalism. Instead they seem to have galvanized it.

The health care journey, then, is far from over. This time, however, it will be progressives and leftists at the helm, with Medicare for All the increasingly discernible destination on the horizon.

Dr. Adam Gaffney is a physician whose work has appeared in Salon, Dissent, and In These Times. He blogs at theprogressivephysician.org.

https://jacobinmag.com…

Single-payer is simpler and fairer

By Susan Miller, M.D.
Richmond (Va.) Times-Dispatch, July 30, 2017

Regarding the Commentary column, “Single-payer ‘dream’ would be a nightmare for Americans,” by Chris Renkar: On the contrary, the Improved Medicare for All Act, HR676, would be a godsend for Americans. The only loser in the fight to expand Medicare is the insurance industry. Under HR676 all Americans are automatically enrolled. All medically necessary care, drugs, equipment, hospitalizations, hospice, dental and eye care are included.

What the promoters of the insurance market fail to admit is that the market for health care is unlike the market for other consumer goods. The ability to make an informed choice about health care services is highly constrained by unequal information between the patient and the physician and the need for services right now.

The ACA exchanges are narrowing and prices are rising because of the failure of the for-profit insurance markets. The reasons for increasing delays in the U.K. are due to the Conservative government trying to privatize the National Health System. In most universal systems, the government collects money to pay the independent physicians, pharmacists, and hospitals for the care of citizens. There will always be a decision about whether taxes go to education, roads or the military versus health care. In the U.S. we ration based on one’s ability to pay. We pay more than twice the per-capita cost of the universal systems and have worse health statistics in nearly all important metrics.

Two things stand in the way of a simpler, less expensive and more fair health care system: political will and the health insurance industry.

This fight is essentially a moral one. Do we believe health care is a commodity or a human right; a social good like education that benefits our entire society by ensuring a competitive workforce and a level playing field for businesses, or just another way to make money from the illnesses of others?

http://www.richmond.com…

Melissa Stiles, MD

Professor of Family Medicine, UW Madison - Linda and Gene Farley Wisconsin Chapter of PNHP

Matt Hahn, MD

Dr. Matt Hahn was the 2006 Maryland Family Physician of the Year and finalist for the 2007 American Family Physician of the Year. His practice is located in Hancock, MD, and he lives in Berkeley Springs, WV. He is a graduate of George Washington University School of Medicine, and completed a residency in family medicine at the York Hospital in PA.

Wayne C. Spiggle, MD

Dr. Spiggle is the founding partner of the Braddock Medical Group, Cumberland. Semi-retired from medical practice, he now consults patients at the Tri-State Community Health Center. He is a county commissioner and serves as the chair of the Episcopal Diocese of Maryland’s Health Care Task Force. Dr. Spiggle is a past president of MedChi, The Maryland State Medical Society. He helped organize Allegany Health Right and is currently involved in the development of WVRx, a prescription assistance program in his native state.

Elizabeth Kurczynski, MD

Dr. Kurczynski is a professor of pediatrics at West Virginia University, Charleston She is a graduate of Case Western Reserve University School of Medicine and the University of Wisconsin. 

Sara Weinberg

Dr. Weinberg is a Retired pediatrician, Mercer Island, and an expert on Washington state’s history of failed health reforms, going back to the 1989 Braddock initiative. Dr. Weinberg graduated from the University of Washington School of Medicine in 1977 and completed her pediatric residency at the University of Washington’s Children’s Orthopedic Hospital.

Hugh Foy

Dr. Foy is a professor of Surgery, UW School of Medicine, and Director of the Surgical Specialties Clinic, Harborview Medical Center. Dr. Foy has extensive experience in emergency care and trauma surgery. He trained at UW, and completed a fellowship in Burn Surgery and Surgical Critical Care at Harborview. Dr. Foy is the co-founder of the Washington Chapter of PNHP.

Don Mitchell, MD

Dr. Mitchell was trained at Harvard and is a retired internist and Chair, Western Washington chapter of PNHP.